BRITISH PARACHUTE ASSOCIATION
SAFETY AND TRAINING COMMITTEE MEETING
COUNTY ARMS, GLEN PARVA, LEICESTER
THURSDAY 7TH DECEMBER 2000
Present:John Saunders - Chairman
Andy Guest - Devon & Somerset
Dane Kenny - Pilgrims
David Hickling - BPS, Langar
Karen Farr - Skydive Strathallan
Dennis Buchanan - NWPC
Phil Cavanagh - Black Knights
Dave Wood - RAFSPA
Andy Paddock - Silver Stars
Carl Williams - Skydive Wales
Pat Walters - Tilstock
Chris Lyall - NLPC
Pete Sizer - Headcorn
Ian Rosenvinge - Peterlee
Paul Applegate - Riggers
Apologies:Ian Cashman (John Horne represented Ian at this meeting), Steve Thomas, Mick Nealis, Mike Bolton.
In Attendance:Tony Butler-Technical Officer
John Hitchen-NCSO
John Carter-BPA Medical Advisor
John Horne-Chairman APA STC
Pete Lambson-Chairman Panel Inquiry
Mr D Savage-Legal Representative
Trudy Kemp-Assistant to NCSO/TO
Jon Dodd
Carl Scarisbrick
Jeff Chandler
Observers:Bernadette Whitaker, John Curtis,, Ian Smith,
Iain Markham, John Gilpin, Rick Boardman, Dave Ballard,
Kim Newton, Richard Wheatley, Mike Rust, Duncan Haynes,
Mike Carruthers, Stuart Morris.
ITEM
1.MINUTES OF THE STC MEETING OF THE 28TH SEPTEMBER 2000
It was proposed by Dane Kenny and seconded by Dave Hickling that the Minutes of the STC Meeting of the 28th September 2000 be accepted as a true record.
Carried Unanimously
2.MATTERS ARISING FROM THE STC MEETING OF THE 28TH SEPTEMBER 2000
Page 1, Item 2 – Foreign AFF/Tandem Instructor Working Group. This item would be dealt with at that evening’s meeting.
Page 1, Item 2, Fatality – Tim Bettin. The Final Panel of Inquiry Report would be considered at that evening’s meeting.
Page 2, Item 2 – Panel of Inquiry, Eaglescott. The Committee was advised that the instructor concerned had been out of the country, and therefore Council did not deal with this item at their meeting of the 17th October, but decided that they would give him the opportunity to Appeal to Council at the Council meeting on the 12th December.
Page 2, Item 4 – Incident/Injury Reports. Michelle Pollard, the instructor who
was seriously injured, was making good progress, as was Mike Cole who was also
badly injured.
Note:-The following item was discussed later on the main Agenda as it was held in camera.
Page 4, Item 4 – Incident/Injury Reports (v). At the last STC a report was discussed regarding a Tandem incident, where an instructor lost his trainer on exit. He did not deploy his drogue, remained in free fall, pulled his drogue release handle, then deployed his reserve just prior to the CYPRES going off. He was subsequently ‘grounded’ from further Tandem jumps by his CCI, until the last STC meeting. The instructor was unable to attend the last STC because of military commitments. Therefore STC decided that because of the seriousness of the incident the instructor was to remain ‘grounded’ until this meeting. The instructor concerned was present at the meeting and gave details of the incident in question.
He was then asked to leave the meeting, whilst STC considered this matter at some length.
Following a lengthy discussion on this matter and because of the serious nature of the incident, Phil Cavanagh proposed that the Instructor’s Tandem Instructor rating is permanently revoked.
A counter proposal was tabled by Pete Sizer that his Tandem Instructor rating be suspended until he was re-assessed on a full Tandem Instructor Course. This proposal failed to find a seconder.
A vote was then taken on Phil Cavanagh’s proposal, which was seconded by Karen Farr that the Instructor concerned’s Tandem Instructor rating is permanently revoked.
For: 11 Against: 0Abstentions: 2 (Dave Wood, Pete Sizer)
Carried
The Instructor was then invited to return to the meeting where he was advised of STC’s decision. He was also advised that he had the right to an appeal, which he could make at the next STC meeting.
Page 4, Item 4 –. Incident/Injury Reports (vii). The Military display misfire mentioned at the last STC, had been investigated by the APA and Ian Cashman would be able to update the Committee at the next meeting.
Page 6, Item 6 – Instructor Courses. Since the last meeting Jim O’Kane had now successfully completed all his required Tandem evaluation jumps and had been awarded his Tandem Instructor rating.
Page 7, Item 7 – 1999 Injury Statistics Report. The Working Group that STC decided should be formed was in the process of being formed and STC would be kept informed of its progress.
3MINUTES AND MATTERS ARISING FROM THE RIGGERS SUB COMMITTEE MEETING OF THE 28TH SEPTEMBER 2000
There being no matters arising from the previous meeting, it was proposed by Paul Applegate and seconded by Pat Walters that the Minutes of the Riggers Sub-Committee Meeting of the 28th September 2000 be approved.
Carried Unanimously
Mr Applegate gave the Committee details of that evening’s meeting and stated that the Riggers had discussed and accepted a request from the RAF Detachment to Special Forces, which was different from the request that went out with the Riggers Agenda and was tabled to those present for Permission to be given to them for a Permanent Exemption for military instructors and selected specialist troops to use 7 cell Fury/Raven/Racer systems packed by RAF fitters under the following conditions:
- At all military and BPA affiliated Drop Zones.
- Full BPA registered parachutists (in accordance with BPA Ops Manual).
- Personnel placed ‘on duty’ whilst parachuting.
- Military Fury/Raven/Racer system with AADs.
- Parachutes holding a current military Record of Inspection sheet.
Mr Applegate advised those present that Riggers had accepted this permission request on the basis that if any changes were made to the above conditions, then the RAF Detachment would need to come back to the Riggers Committee for another ‘request’ to be considered.
It was proposed by Dane Kenny and seconded by Andy Guest that the above permission be accepted.
Carried Unanimously
4.FATALITY – BORDER PARACHUTE CENTRE (New Agenda Item)
The Chairman advised those present that tragically a fatal accident occurred at the Border Parachute Centre on the 25th November. The parachutist killed was Colin Graham who was making his second jump following his training and first jump on the 11th November. Colin had made two or three jumps previously a few years ago.
After throwing a WDI the aircraft climbed to 3,500 ft, during which time the Jumpmaster gave the Colin a pre-jump check. The aircraft then ‘ran in’ over the top of the PLA, at which time the he was instructed to climb out and hang from the wing strut. During the climb out the he bumped his container on the door, (not uncommon for this type of aircraft), but the closure flaps on the container were not disturbed.
He made a good release from the aircraft, maintaining a good body position. As the parachute started to deploy he was seen to break his position to a slightly back to earth position, with his legs forward. He was also observed to turn, possibly to the left. His arm was seen to go back, possibly between the rigging lines or risers and come out again.
The parachute was seen to fully deploy, but was observed to be turning to the right. Shortly after deployment the reserve parachute pilot chute and a short length of bridle line were seen to be trailing from the container.
At approximately 1,500 ft the main parachute released from the harness, though one side was seen to remain attached for a few seconds before it released. At which stage the he was observed in free fall with the pilot chute, bridle line and reserve deployment bag in ‘tow’, with no further deployment of the reserve parachute until impact.
A Board of Inquiry was formed, consisting of John Hitchen, Ian Rosenvinge and Brian Dyas. The Board have completed their Report and their Conclusions and Recommendations are as follows:
CONCLUSIONS
The Conclusions of the Board are that the Colin’s initial exit from the aircraft was good, but as the main parachute started to deploy he may have caught is right arm in the risers or rigging lines, or the riser/rigging lines may have caught on some part of his equipment, causing the main parachute to distort on full deployment.
Shortly after the reserve pilot chute extracted, either because the reserve container closure pin had been caught by something, or the he had activated the reserve himself.
Because the main canopy was fully inflated, the reserve pilot chute could have dropped through the reserve parachute rigging lines and caught around the reserve parachute free bag ‘mouth lock’, preventing the reserve parachute from extracting from the bag.
At approximately 1,500 ft the he release his main parachute, but because of the reserve parachute ‘bag lock’ there was no reserve parachute deployment.
RECOMMENDATION
The Recommendation of the Board is that the subsequent Panel of Inquiry, which follows this Board of Inquiry, considers the following:
a)That previous incidents of a similar nature are studied to determine as to whether there are any common problems or equipment issues that may be relevant.
b)As to whether two handed reserve drills for Student Parachutists may be better for preventing out of sequence reserve deployments.
The Chairman stated that the Board of Inquiry Report required acceptance by STC.
It was therefore proposed by Carl Williams and seconded by David Hickling that the Board of Inquiry Report be accepted.
Carried Unanimously
The Chairman thanked the Board Members for their assistance with the Inquiry and advised those present that as usual a Panel of Inquiry would be convened to look into the peripheral aspects of the fatality.
- INCIDENT/INJURY REPORTS – RESUME (Previously Item 4)
i)There had been 27 Student injuries since the last meeting, 16 male and 11 female. One Student broke a collar bone during PLF training, one got ‘whip lash’ on deployment and one perforated an eardrum descending in the aircraft. The rest of the injuries were landing injuries, including one Student who landed in a tree, cutaway and fell approximately 20ft injuring herself badly (broken wrist, leg and collapsed lung). 23 of the injuries were on ram-air canopies and 1 was on an aeroconical canopy.
ii)There had been 7 injuries reported to Intermediate or Experienced Parachutists since the last STC. 4 male and 3 female. These included two female parachutists who collided under canopy at approximately 150ft. One canopy entangled with the other jumper’s wrist. One canopy collapsed and they both landed very heavily, both fracturing their pelvises amongst other injuries. The Committee was advised that both parachutists were progressing well.
iii)Since the last meeting there had been 14 Student Parachutist Malfunctions/Deployment Problems reported. 13 male and 1 female. All were on ram-air canopies.
iv)There had been 15 reports of Malfunction/Deployment Problems to Intermediate or Experienced Parachutists since the last meeting. 11 male and 4 female.
v)There had been 7 Tandem Incident/Injury reports received since the last meeting. Five were malfunctions/deployment problems. Two were broken ankles.
vi)One report had been received of an AAD firing. A Category 8 jumper lost altitude awareness and deployed his main as the FXC fired.
vii) There has been a couple of ‘off landing’ reports received, both at clubs and a Student lost his helmet on deployment.
Note:-The following item was discussed later on the main Agenda as it was held in camera.
The Chairman gave details of an incident which occurred where a parachutist jumped from approximately 1,500 ft over Coventry Airport, had a problem and landed on the roof of a building injuring himself. A DC3 had been hired to drop poppies over Bedworth near Coventry and the parachutist and the pilot came to an agreement for the parachutists jump on the way back. This jump was not notified to the BPA or NATS as a display. The jumper concerned is a display team leader. He had been written to asking for his comments and advising him that this would be discussed at this STC meeting. He was unable to attend the meeting, but had written a statement, which was circulated to those present, together with a letter from the aircraft operators.
The Committee discussed this item at some length and they felt that this incident was a blatant breach of the BPA Operations Manual and the behaviour of the jumper was outrageous particularly because of the fact that he was a current Display Team Leader and the incident itself had caused a great deal of media coverage.
Following further discussion on this matter, it was proposed by David Hickling and seconded by Dane Kenny that the jumper concerned be ‘grounded’ and that his Display Team Leader’s rating is suspended until he presents himself to the Committee. It was also proposed that STC recommend to the BPA Council that they consider the fact that Mr Clements may have brought the sport in disrepute and that they may wish to consider suspending his BPA membership.
Carried Unanimously
- PANELS OF INQUIRY (Previously Item 5)
Note:-This item was discussed later on the main Agenda as it was held in camera.
A)PANEL OF INQUIRY INTO THE FATAL ACCIDENT OF TIMOTHY BETTIN ON THE 28TH MAY 2000 – FINAL REPORT
A Panel of Inquiry Report was initially sent out with the Agenda, followed last week by the Final Report, which was the one that was dealt with that evening.
Jon Dodd was present at the meeting, together with his legal representative; Mr David Savage.
The Conclusions and Recommendations of the Panel are as follows:
CONCLUSIONS
- There were 2 breaches of the BPA operations manual :-
1).SECTION 13, PARAGRAPH 6, SUB PARA 6.2. (CURRENCY).
Tim Bettin had failed to carry out a minimum of 10 descents in the 3 months prior to the display.
2).SECTION 13, PARAGRAPH 6, SUB PARA 6.1. (CURRENCY).
Jon Dodd as team leader failed to ensure the currency of his team members prior to the display.
B. There were no breaches of the teams own written procedures, however the Panel feel that the team leader had some misconception concerning the marginal weather conditions and Tim’s previous experience overall.
C. All team members who carried out the display completed a DZ recce, with the
exception of Roger Shapland. All were fully briefed prior to emplaning and were also current and qualified.
- The Panel concludes that although a great deal of clubs were not operating due
to excessive wind speeds, it is very difficult to monitor this situation at display arena’s.
RECOMMENDATIONS
A. Due to the breach of the BPA operation’s manual by the team leader, the Panel recommends that Mr Jon Dodd’s team leader’s rating is withdrawn for a period of 2 years from 01-01-01, also that this period should include the rest of this current calendar year (2000).
B. Jon Dodd should not be permitted to act as a jumpmaster on any display or display team. This recommendation should last for the same period as the above.
- The Panel feel that this is a pertinent time to remind all display team leaders’ of their very important responsibilities.
Mr Savage raised a number of objections with regard to STC procedures.
The Chairman stated that STC had an established procedure, which is laid down. He stated that it is STC’s duty to look at the Panel Report and to vote on the Recommendations.
The Chairman explained that Mr Dodd would be given the opportunity to put forward his case and to answer any questions from the Committee. STC would then discuss the matter ‘in camera’ to consider the Panels Recommendations.
.
STC invited Mr Dodd to put forward his comments in relation to this incident for STC to consider.
Mr Savage then read out Mr Dodd’s representations to the Panels report and Recommendations.
Mr Dodd was then invited for his comments.
Mr Savage asked permission for a number of letters of support of Mr Dodd in relation to the Panel findings to be distributed to those present.
The Chairman pointed out that the letters in question were in support of an appeal against the findings of the Panel. The Chairman therefore pointed out that the letters were not relevant at this time and stated that if they became relevant at a future stage then they would be circulated.
Mr Savage asked the Committee if Mr Ian Smith who was DZ Controller on the Display in question could be invited to give evidence.
This request was denied on the basis that this was not an appeal hearing and it was not the appropriate time for witnesses to be present.